Advance Care Planning and Limited English Proficiency

Geriatric Cardiology Perspective:

  • The congruence of an aging population with cardiovascular diseases along with the increasing prevalence of multiple chronic conditions will challenge healthcare systems and the cardiovascular team with increasingly complex medical decisions.
  • In the United States between 1990 and 2013, the limited English proficient (LEP) population grew by almost 80% (14 million to 25.1 million).
  • There is increasing recognition that addressing language barriers represents a key "best practice" in cardiovascular clinical care.
  • Furthermore, an ethical imperative exists to address language barriers in cardiovascular medicine, particularly in relation to goals of care discussions. 
  • Cardiovascular team members should have the skills to identify language barriers and offer professional interpreter services to all patients who express a language preference other than English, regardless of their language proficiency.  
  • Use of ad hoc interpreters (family members, friends) and non-certified bilingual staff should be avoided unless professional interpretation is refused by patients or family members. 
  • Advance care planning (ACP) is a process that allows patients at any age or stage in health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.
  • Unfortunately, ACP rates are low among patients with LEP, and until recently, easy-to-use ACP tools for patients with LEP and limited health literacy were not available.
  • The cardiovascular team can play an important role in helping their patients, including patients with LEP, engage in ACP by providing them easy to use ACP tools in their preferred language (

Editor's note: Commentary based on Gonzalez R, Lyon L, Rabbani J, et al. The association of Spanish language preference with advance directive completion. J Am Geriatr Soc 2021;69:122–28.1

Rationale for Study: Recent data suggests lower engagement of completion of advance directives among patients with LEP compared to English native speakers Moreover, little is known about the association between language of preference and the implementation of advance directive planning in patients with cardiovascular disease.

Funding: Kaiser Permanente Northern California (KPNC) Community Benefit Program Grant 9940-RNG209457

Study Design: Observational study.

Cohort: Sample consisted of Hispanic (N=108,371) and non-Hispanic White (N=512,577) members of KPNC members aged 55 or older with >5 consecutive years of membership with KP. Among Hispanic patients, language of preference was self-reported and classified in 3 language preferences including:
-English preferred,
-Spanish preferred, and
-Spanish preferred and needing an interpreter

Exposure: Completion of advance directives (AD) among 620,948 KPNC members, between January 2013, and December 2017.

Primary predictive variables:
Ethnicity, Linguistics preference, 3 levels: English preferred, Spanish preferred, Spanish preferred and needing an interpreter.

Outcome(s): Having an AD filed in the organizational medical records within the past 10 years.

Statistical Analysis:

  • Standard descriptive statistics were used to report the distributions of predictors and control variables for the Hispanic and non-Hispanic subgroups.
  • Pearson chi-square statistics were calculated for group comparisons.
  • Multivariate regression analysis was used to adjust for demographic and socioeconomic factors among Hispanic groups.


  • Hispanic patients were younger, however had more comorbidities, higher levels of poverty and lower educational levels.
Demographic and clinical characteristics of Non-Hispanic whites and Hispanics
Characteristics Non-Hispanic Whites Hispanics
Age 55-64 37.4% 48.4%
Charlson comorbidity score > 3 19.3% 21.0%
Living in communities with higher poverty levels 29.1% 50.7%
Head of household with high school educational level or less 22.5% 50.1%
  • Standardized advance directive (AD) completion by ethnicity and Spanish language preference are as follows:
    • Non-Hispanic White: 20.3%
    • Hispanic, English Speaker: 12.6%
    • Hispanic, Spanish speaker, no need for an interpreter: 6.4%     
    • Hispanic, Spanish speaker, needs an interpreter: 5.3%
  • An inverse relationship was demonstrated between Spanish speakers who needed and the interpreter and completion of AD.
  • Hispanics who were least English proficient and required interpreter services had the lowest rates of completion of AD among all Hispanic groups.
  • Negative predictors for completion of AD included living in a community with more Spanish speakers (OR: 0.9, CI=0.8-0.9), living in a poor neighborhood (OR: 0.9, CI=0.8-0.9) with poor educational attainment (OR: 0.9, CI=0.8-0.9).
  • Positive predictors for completion of AD included being a female (OR: 1.4, CI=1.3-1.4), older age (OR: 6.3, CI=5.9-6.8), higher frailty score (OR: 1.4, CI=1.4-1.5), higher hospitalizations (OR: 6.8, CI=6.3-7.3).

Limitations of study:

  • Inability to measure the role of cultural beliefs and other socioeconomic factors that may affect patient's preferences and health care utilization.
  • Unable to measure the modality of interpretation used during patient-provider encounters.


  1. Gonzalez R, Lyon L, Rabbani J, et al. The association of Spanish language preference with advance directive completion. J Am Geriatr Soc 2021;69:122–28.

Clinical Topics: Geriatric Cardiology, Cardiac Surgery, Cardio-Oncology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease

Keywords: Geriatrics, Aged, Self Report, Ethnic Groups, Frail Elderly, Cardiovascular Diseases, Hispanic Americans, Language, Linguistics, European Continental Ancestry Group, Family Characteristics, Patient Acceptance of Health Care, Medical Records, Advance Directives, Comorbidity, Regression Analysis, Hospitalization, Communication Barriers

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